Impact of Moderate versus Deep Sedation and Trainee Participation on Adenoma Detection Rate-Analysis of a Veteran Population

Background/Aims@#The adenoma detection rate (ADR) is used as a quality indicator for screening and surveillance colonoscopy. The study aimed to determine if moderate versus deep sedation affects the outcomes of the ADR and other quality metrics in the veteran population. @*Methods@#A retrospective review of colonoscopies performed at Memphis Veterans Affairs Medical Center over a one-year period was conducted. A total of 900 colonoscopy reports were reviewed. After exclusion criteria, a total of 229 index, average-risk screening colonoscopies were identified. Data were collected to determine the impact of moderate (benzodiazepine plus opioids) versus deep (propofol) sedation on the ADR, polyp detection rate (PDR), and withdrawal time. @*Results@#Among 229 screening colonoscopies, 103 (44.9%) used moderate sedation while 126 (55%) were done under deep sedation. The ADR and PDR were not significantly different between moderate versus deep sedation at 35.9% vs. 37.3% (p=0.82) and 58.2% vs. 48.4% (p=0.13), respectively. Similarly, there was no significant difference in withdrawal time between moderate and deep sedation (13.4 min vs. 14 min, p=0.56) during screening colonoscopies. @*Conclusions@#In veterans undergoing index, average-risk screening colonoscopies, the quality metrics of the ADR, PDR, and withdrawal time are not influenced by deep sedation compared with moderate sedation.

Impact of Moderate versus Deep Sedation and Trainee Participation on Adenoma Detection Rate-Analysis of a Veteran Population

Background/Aims@#The adenoma detection rate (ADR) is used as a quality indicator for screening and surveillance colonoscopy. The study aimed to determine if moderate versus deep sedation affects the outcomes of the ADR and other quality metrics in the veteran population. @*Methods@#A retrospective review of colonoscopies performed at Memphis Veterans Affairs Medical Center over a one-year period was conducted. A total of 900 colonoscopy reports were reviewed. After exclusion criteria, a total of 229 index, average-risk screening colonoscopies were identified. Data were collected to determine the impact of moderate (benzodiazepine plus opioids) versus deep (propofol) sedation on the ADR, polyp detection rate (PDR), and withdrawal time. @*Results@#Among 229 screening colonoscopies, 103 (44.9%) used moderate sedation while 126 (55%) were done under deep sedation. The ADR and PDR were not significantly different between moderate versus deep sedation at 35.9% vs. 37.3% (p=0.82) and 58.2% vs. 48.4% (p=0.13), respectively. Similarly, there was no significant difference in withdrawal time between moderate and deep sedation (13.4 min vs. 14 min, p=0.56) during screening colonoscopies. @*Conclusions@#In veterans undergoing index, average-risk screening colonoscopies, the quality metrics of the ADR, PDR, and withdrawal time are not influenced by deep sedation compared with moderate sedation.

Cystic lesions of lung in infancy

Objective: to describe clinical presentations, investigations performed for diagnosis, treatment provided and outcome of cystic lesions of the lung in infancy

Study design: descriptive case series

Place and Duration of Study: department of Paediatric Surgery, National Institute of Child Health Karachi, from January 2010 to February 2012

Methodology: infants admitted with respiratory distress and later suspected of having structural / anatomical cause for the dyspnea were included. X-ray chest was performed in all the cases. CT scan was advised for detail assessment

Results: a total of twelve patients were managed during the study period. There were seven male and five female patients. Seven lesions were in left lung and five in right lung. This included seven cases of congenital lobar emphysema [CLE], two of pneumatocele, one each of bronchogenic cyst, isolated lung cyst and necrotizing pneumonia. All patients underwent thoracotomy and procedure was tailored according to the pathological lesion. Excision of involved segment of lung was performed in cases of CLE [five left upper lobes and two right middle lobes] and necrotizing pneumonia [right upper lobe]. Lung cyst was found in the fissure between right upper and middle lobes. In two cases of pneumatocele cyts were opened and after partial excision of the wall. Margins of cysts were over sewed. In a single case of bronchogenic cyst which was adherent to left bronchus excision of cyst and repair of bronchus was done. One patient died in this series

Conclusion: cystic lesions presents in a spectrum; most common being acute respiratory distress. An early diagnosis and prompt surgical intervention is required to prevent morbidity and mortality

Pathology of high altitude pulmonary oedema

To describe autopsy findings in fatal cases of high altitude pulmonary oedema. Descriptive study. The study was carried out between 1999 and 2002 at an army field medical unit in Baltistan, Armed Forces Institute of Pathology, Rawalpindi and Army Medical College, Rawalpindi, Pakistan. Autopsies were performed in 17 fatal cases of High Altitude Pulmonary Edema [HAPE] occurring among soldiers serving in Siachen. All cases were males with a mean age of 26.8 years [19-35]. The mean altitude at which HAPE occurred was 5192 meters [2895-6492], and the mean duration of stay at these altitudes was 15.3 days [1-30]. Eleven individuals had undergone proper acclimatization. The commonest clinical findings were cough [70%] dyspnoea [53%], nausea [47%], headache [41%], vomiting [35%], chest pain [35%] and tightness in chest [24%]. Cyanosis and frothy secretions in the nostrils and mouth were present in all but one case. Mean combined weight of lungs was 1470 grams [1070-1810]. There was marked congestion of outer and cut surfaces. Interstitial oedema was present in all cases. RBCs and leukocyte infiltrates were seen in 13 and alveolar hyaline membranes in 9 cases. Thrombi were seen in 2 cases. Cerebral oedema was present in 9 cases. HAPE can occur after more than two weeks of stay at high altitudes despite proper acclimatization. Concomitant cerebral oedema is frequently present. Our autopsy findings are consistent with what has been reported previously

Laparoscopy in children

Objective: To analyze data related to different laparoscopic procedures performed on children so as to document pattern over the years at a public sector hospital

Study design: Retrospective chart review

Place and Duration of study: Department of Paediatric Surgery National Institute of Child Health Karachi, from January 2011 to December 2013

Methodology: The data of all the laparoscopic procedures was reviewed for the indications, type of surgical procedure performed, operative details including time taken for completion of the procedure, difficulties / conversion rate and complications. Data was entered into SPSS version 16 and descriptive statistics were used for analysis

Results: Total number of patients who underwent laparoscopic procedure was 201. There were 164 [81.6%] males and 37 [18.4%] females. Most of the patients [n=122 - 60.7%] were above five year of age. Clinically impalpable testis [n=124 - 61.7%]] was the most common surgical condition for which laparoscopy was performed. This included first, second stage Stephen Fowler procedure, single stage orchiopexy and orchiectomy. Other procedures included appendectomy [n=27-13.4%] and cholecystectomy [n=12 - 6%]. Diagnostic laparoscopy was performed in 11 [5.5%] babies with persistent jaundice to find out surgical cause of hyperbilirubinemia. There were 7 [3.4%] cases with disorders of sex development [DSD]. Complications occurred in 19 patients which included port site infection [n=8], port site bleeding [n=5], bowel injury [n=2] and others. In only seven [3.5%] cases procedure was converted to open surgery

Conclusions: Laparoscopy was a safe surgical procedure in children performed for different indications. Learning curve over period improved procedure related outcome

Diagnostic yield of pleural fluid cytology in malignant pleural effusion

Pleural effusion is a common presenting feature of patients presenting in the pulmonology OPD. Examination of pleural fluid obtained by thoracocentesis is a simple way to diagnose pathologies of the pleura and peripheral parts of the lung. To determine the diagnostic yield of pleural fluid cytology in malignant pleural effusions keeping pleural biopsy as the gold standard. This retrospective study was carried out at Pakistan Institute of Medical Sciences, Islamabad, from November 2010 to November 2011. Twenty six patients [65% females; 35% males] presenting with pleural effusion in whom pleural fluid cytology with concurrent pleural biopsy was carried out were included in the study. The diagnostic yield of pleural fluid was determined keeping pleural biopsy as the gold standard. The age range of the patients was 23-76 years. Pleural fluid was positive for malignant cells in 15 out of 26 patients, whereas pleural biopsy yielded definite evidence of malignancy in 21 cases. In 5 cases diagnosis of atypical infiltrate was rendered and immunohistochemistry was suggested for confirmation of malignancy. The diagnostic yield of pleural fluid cytology came out to be 58%. Pleural fluid cytological examination followed by pleural biopsy remains the initial diagnostic procedure in management of patients with suspected malignant pleural effusion.

Radiographic assessment of quality of root canal treatment

Root canal treatment quality has a direct bearing on healing in the periradicular area. There are various methods to assess the quality of root canal treatment. Radiographic assessment in conjunction with clinical assessment remains one of the most commonly employed methods to predict the prognosis of endodontically treated teeth. The objective of this study was to assess the quality of root canal treatments of patients, reporting to outdoor clinics of a dental college. It was a cross sectional study carried out over a period of six months. A total of 248 patients, with at least one endodontically treated tooth, reporting to the outdoor clinics of Lahore Medical and Dental College were included in the study. Quality of root canal treatment was assessed radio graphically. A predetermined criterion, based on length and lateral seal of the root filling already used in earlier studies, was employed. The technical quality of root canal treatment was assessed to be adequate in 52.4% of the observed cases which is in contrast to the high percentages of reported success rates for this modality

Gaining retention, support and stability of a maxillary obturator

Construction of a maxillectomy obturator for any surgical defect requires optimum retention, stability and obturation of defect. In the following case a closed hollow bulb obturator was constructed while utilizing surveying and neutral zone impression technique. After insertion, soft liner was applied to record functional impression of the surgical defect. The obturator was resurfaced with heat cure acrylic to improve the outcome. Patient was able to masticate adequately and speak comprehensively. Patients' resonance, speech, retention and stability were markedly improved. Follow-up was done weekly in first month, fortnightly for the next 2 months then after every 3 months. In succeeding years it will be once every year

Relationship of neutral zone and alveolar ridge with edentulous period

To estimate the amount of shift in position of the neutral zone and the centre of alveolar ridge crest in different edentulous periods. Observational study. The study was carried out on edentulous patients reporting in Prosthodontics Department of Lahore Medical and Dental College, Lahore, from August 2006 to December 2008. Patients with edentulous period for at least 6 months exhibiting normal range of maximal mouth opening [40-50 mm] and normal temporomandibular joint movements were included and allocated into two groups, according to period of edentulism. Patient with any intra oral soft tissue or bony pathology and reduced intermaxillary space were excluded. The neutral zone was clinically recorded for all patients with impression compound. The shift between neutral zone and ridge crest in different edentulous periods was analyzed radio graphically and compared statistically. In longer edentulous period [>2 years], neutral zone was lingually shifted by an average of 1.06 mm in anterior, premolar and molar regions. Neutral zone may be lingually shifted in relation to alveolar ridge crest in patients with prolonged edentulous period. This may help in arranging the teeth according to the clinical situation

Neutral zone dentures versus conventional dentures in diverse edentulous periods

The objectives of this study were to compare the arrangement of teeth according to the bone support concept with the neutral zone concept, Evaluate the influence of two arrangement schemes on denture success. A total of 128 patients were equally allocated into two groups, according to period of edentulism. All groups were provided neutral zone and conventional dentures. Post insertion assessment of conventional and neutral zone dentures was compared. Both denture techniques showed satisfactory assessment results in shorter edentulous period. In longer edentulous period, neutral zone dentures showed better assessment results. Arrangement of teeth with neutral zone may improve denture success in patients with prolonged edentulous periods

Floating death in pericardium

A 12-year-old boy referred from another facility after sustaining stray bullet injury to chest on left side with no exit wound. He remained stable through out although chest intubation was done in referring hospital. In our Emergency Room he remained well therefore shifted to surgical unit. Investigations revealed bullet in pericardial cavity. It was decided to remove the bullet on elective basis. Surgery was deferred at the request of parents. Six months later child was operated. Initially thoracoscopy was performed but it was converted to open thoracotomy as bullet could not be identified. It was then retrieved easily from paricardial cavity. Post operative recovery was uneventful

Splenic hydatid cyst: a rare site of involvement

A case of splenic hydatid cyst is reported in which the only complaint was left sided abdominal pain. Hydatid disease was diagnosed on ultrasound abdomen and CT scan. IHA was also significantly raised. Patient was kept on albendazole pre-operatively. On splenic exploration due to the presence of good splenic tissue cystectomy and capitonnage was done

Intralesional bleomycin injection- A primary therapy for peripheral lymphangiomas

To evaluate the efficacy of intralesional Bleomycin Injection [IBI] as a primary therapy for peripheral lymphangiomas in children. A prospective study was conducted at NICH Karachi from January 2003 to December 2005. Patients with peripheral lymphangiomas were included in the study. Exclusion criteria included previously treated lymphangiomas, infected lesions, intra-thoracic and intra-abdominal lesions. Thirty three patients were included in the study. All were treated with Intralesional Bleomycin Injection [IBI]. After aspiration of fluid from the lesion, 0.5 mg/kg of Bleomycin diluted in saline was administered at different sites into the lesion. Depending upon the size of lesion and age of patient, procedure was performed in operating theatre under local or general anesthesia. Reduction in size was seen in 90% cases [n=29], out of them 30% [n=10] showed near complete disappearance and 63% [n=21] showed good response. Two patients [6%] showed poor response and they underwent surgery. Few patients had minor complications like fever, pain, redness and increase in the size after injection. All these complications were managed conservatively with symptomatic treatment and no patient required hospitalization. IBI is an effective therapy for lymphangiomas, with results comparable to surgical excision. It has the added advantage of avoiding inadvertent injury to vital structures, scarring and other complications of surgery. We recommend it as a primary therapy for all peripheral lymphangiomas

Surgical management of renal tumors in children

To analyze case records of children with renal tumors. Case series. Surgical Unit B, National Institute of Child Health, Karachi during years 2004-2005. Case records of all patients managed during the study period were reviewed for clinical presentation, investigations and surgical management. National Wilms' Tumor Study. Group [NWTSG] and International Society of Pediatric Oncology [SIOP] protocols were used depending upon stage in cases of Wilms' tumor. Trucut biopsy was done for tissue diagnosis as proposed by UK Children's Cancer Study Group [UKCCSG]. Touch imprints were also made. Surgical procedure was analyzed in terms of ease of dissection, tumor spillage and extent of excision. Twenty-one patients of renal tumors were managed in two years period. Nearly 60% of patients were less than 2 years of age. Majority [n 14] presented with abdominal mass. Few had complaints of abdominal pain. One patient an infant, presented with profuse hematuria. Trucut biopsy was done in 18 cases to have tissue diagnosis. Three patients underwent primary exploration. There were 17 cases of Wilms' tumor and in one case it was suspected on touch imprints. Fourteen patients of Wilms' tumor were given pre operative chemotherapy [SIOP protocol]. Twelve of them were in stage III and IV. Nine out of this have undergone nephrectomy. Marked tumor regression in size of tumor was noted. The tumor also became firm. Only one tumor ruptured during excision. In one tumor with horse-shoe kidney, residual tumor left at margins of dissection. Three patients underwent primary nephrectomy. Two of these were in stage I and one in stage III [NWTSG protocol]. Patient in stage III died in immediate post operative period because of hemorrhage. There was one case each of mesoblastic nephroma, cystic nephroma and rhabdoid tumor. In all these nephrectomy was done following trucut biopsy. Patient with rhabdoid tumor received pre operative chemotherapy. This tumor ruptured during surgery and gross spillage occurred. Wilms' tumor was the most common pediatric renal tumor. Most of the patients were younger than the reported age and presented with advanced stage of disease. SIOP protocol found more appropriate in our group of patients

Childhood nephrectomies for benign renal lesions

To conduct an audit of nephrectomies done in children for benign renal pathology. Evidence based study. Place and Duration: National Institute of Child Health, Karachi, during the year 2004-2005. The record of all the paediatric age group patients undergoing unilateral nephrectomy for benign renal diseases over a 2-year period were reviewed for the underlying diagnosis and indication for nephrectomy. Patients of Wilms` tumor subjected to nephrectomy were excluded. In the study nephrectomy was carried out in a total of 12 patients. There were 8 males and 4 females. The age range was 4 to 12 years. Nephrectomy was performed for renal tuberculosis in 5, pelvi-ureteric junction obstruction [PUJO] in 5, congenital hypoplastic kidney in 1 and one for multicystic dysplastic kidney. All the patients following nephrectomy remained well in the immediate post operative period and thereafter. Late presentation and delay in diagnosis of benign lesions of the kidney remained the main culprit in loosing a vital organ in childhood

Morphological spectrum of gastric lesions - endoscopic biopsy findings

A retrospective study was carried out to determine the morphological spectrum of gastric lesions at Pathology Department of Army Medical College, Rawalpindi for the duration of 02 years. Descriptive Study. The gastric mucosal biopsies of 787 patients received from Gastroenterology unit of Military Hospital Rawalpindi from January 2002 to December 2003, were studied by routine histopathology methods. A high frequency of gastric disease in males with a male to female ratio of 6:1 and an age range of 09 years to 85 years were observed. The clinical presentations mostly seen were abdominal pain, dyspepsia, vomiting, diarrhoea, decreased appetite and weight loss. On endoscopy the most frequently suspected lesions were gastritis 662[84.12%], stomach growth 45[5.72%], gastric ulcers 10[1.27%], while 70[8.89%] cases showed unremarkable mucosa. The histopathology revealed chronic non-specific gastritis 676[85.89%] followed by malignant tumours 45[5.72%], benign neoplasms 3[0.38%] and gastric ulcer 10[1.27%]. A number of biopsies 53[6.73%] were unremarkable histologically. The more prevalent lesions in this series were chronic active gastritis followed by tumours and gastric ulcers. H. pylori associated gastritis was seen in majority of the patients. Thus gastric biopsy is an essential tool for diagnosis and confirmation of clinically suspected cases

Neonatal cholestasis Syndrome: an experience at Army medical college and Military Hospital Rawalpindi

To find the causes of neonatal cholestasis in our set up and to see the role of liver biopsy in differentiating neonatal hepatitis from biliary atresia. Design: A cross sectional survey. Place and duration of study: Histopathology department of Army Medical College and Military Hospital Rawalpindi from January 2000 to December 2004. Patients and A total of 62 cases were studied with age range of 1.5 months to 5 years. The subjects selected for biopsy were children with persistent jaundice and hepatosplenomegaly. The biopsy was taken with the help of Surecut needle under the cover of diluted intravenous Ketamine. The fixed tissues were processed under standard conditions. Result: Majority of the patients [62.90%] were of biliary atresia followed by neonatal hepatitis [27.42%]. Paucity of bile ductules was seen in 3 cases while three patients were of indeterminate etiology. Cirrhosis of liver was noted in 10 patients; six because of biliary atresia and two cases each of alpha-1 antitrypsin deficiency and galactosemia. Amongst neonatal hepatitis cases most of the patients were idiopathic in nature [58.82%]. In our set up, biliary atresia is an important and main cause of neonatal cholestasis and liver biopsy is a valuable diagnostic tool in differentiating biliary atresia from neonatal hepatitis

Congenital pyloric atresia: Isolated and associated with aplasia cutis congenita

Two cases of congenital pyloric atresia [CPA] are, hereby, reported. One was suspected on antenatal ultrasound and turned out to be an isolated anomaly. Other patient had a rare association of aplasia cutis congenita with congenital pyloric atresia. The lesions of aplasia cutis congenita were multiple while congenital pyloric atresia was of type II. The patient with an isolated lesion survived following surgery while the other baby died of sepsis in postoperative period

Thymolipoma in a child [a case Report]

A 2 year old male child with history of mild respiratory difficulty and repeated chest infection on CT scan, found to have an anterior mediastinal mass, which pre operatively was suspected as thymolipoma. Through median sternotomy mass was removed in totto. Histopathology confirmed the pre operative diagnosis. Post operative recovery was uneventful. At 6 months follow up there was no recurrence

Hypertrophic pyloric stenosis in a premature. A case report

A four day old baby girl weighing 1.3 kg admitted with respiratory distress. She was delivered by Caesarean section prematurely at 30'h week of gestation due to early rupture of membrane without labor pains. There was no birth asphyxia. She was provided incubator care. As baby was vomiting NG tube was placed. She had non bilious vomiting whenever trial feed given. Surgical opinion was the sought. X ray abdomen showed large gastric shadow with paucity of gas in rest of the abdomen [Figure I]. A diagnosis of malrotation was made. Baby was thus explored. At laparotomy gut was found normally placed with normal caliber of the duodenum. Pylorus was found thickened with dilated stomach. Its appearance was not very classical. Pyloromyotomy was attempted. During the procedure perforation occurred at duodenal end that was closed. Post-operative recovery was uneventful. Baby was put on TPN for 4 days. Trial feed started which was tolerated and then beast feed allowed. She was later discharged